Conclusiones

To investigate the need for integrated services among treatment seeking patients with a substance use disorder and ASAM taxonomy for Dual Diagnosis programmes, we analysed prevalence and characteristic differences between patients who received Dual Diagnosis programme recommendations and those who do not in a third paper. We found that a total of 37% of the patients received Addiction Only Services recommendation, 16% Dual Diagnosis Capable, and 47% were recommended for Dual Diagnosis Enhanced programmes. This showed a high prevalence, and compared with prior research showing 32% to 65% patients with co-occurring disorders (Bakken et al., 2005); the number of Dual Diagnosis programmes recommendation by ASAM seems to be justified.

4.5.1. Characteristic differences between the three groups

Baseline characteristics reveal a significantly lower age and work experience among Dual Diagnosis Enhanced recommended patients compared to Addiction Only Services and Dual Diagnosis Capable group. More patients in both Dual Diagnosis groups report having a confirmed psychiatric diagnosis, but the differences between the groups are not significant. The history of significantly more psychiatric treatments in the Dual Diagnosis Capable and Dual Diagnosis Enhanced group compared to Addiction Only Services group indicates a higher psychological severity, maybe even chronicity within these groups, which in turn can be viewed in favour of ASAM Criteria. We expected a greater severity in those groups if the taxonomy of ASAM Criteria is correctly designed and can discriminate between patients. This

notion further strengthens with clinicians reporting higher percentage of patients with moderate to severe psychiatric disorders in the Dual Diagnosis groups, significantly higher reports for PTSD and psychosis.

4.5.2. Show rate and retention

No differences were found on showing up for assigned treatment, like previous research has found when studying patients with a substance use disorder and a co-occurring psychiatric disorder (Angarita et al., 2007). To secure transitions from one LOC to another, there has been a greater coordination between the clinics in this region, and patients are given information about the treatment before they enter to reduce anxiety and stress during

transitions. This might explain the greater show rate for treatment we see for all three groups in our region compared to a previous study. For retention, a higher percentage in the Dual Diagnosis Enhanced recommended group dropped-out of treatment within the first three months (45% drop out compared to 33% and 34% in the other groups), but the difference between the groups was not significant.

4.5.3. Suicide attempt and outcome differences at three month Follow-Up Higher proportion of suicide attempts have been seen among patients with co-occurring disorders in prior research (Bakken & Vaglum, 2007; Darke et al., 2004), and also in our study we see the highest reported attempts in the Dual Diagnosis Capable and Dual Diagnosis Enhanced group. However no significant differences were found and there are even fewer differences between the groups on thoughts about suicide and tangible plans. One possibility is that ASAM Criteria considers responses on additional questions regarding imminent danger for the patients, by themselves or others, to recommend a suitable LOC for the patients.

Discussion

70 There are significantly more reductions three months after treatment initiation in severity among the Addiction Only Services and Dual Diagnosis Enhanced group on the ASI CSs than for the Dual Diagnosis Capable group. The results might be explained by the fact that the Dual Diagnosis Capable group included older patients and more females than the other two groups. This group also has a higher percentage reporting alcohol as main drug of choice, which could affect the treatment outcome. Older patients might be more engaged in their treatment planning and decisions, but might also have more chronic disorders, more cognitive deficits from alcohol abuse and thus are more resistant to treatment. Or they are in such a stable state that their severity gets underestimated both by themselves and the assessment personnel placing them. Issues regarding self-report measures on psychiatric symptoms from patients have been brought up, and Cole and Sacks (2008) found that patients are more likely to underestimate their psychiatric suffering thus creating a lower prevalence than in reality. This can lead to less attention and treatment for co-occurring psychiatric disorders among this group and might explain the lack of significant reduction on all dimensions except for

Alcohol and Drug ASI CSs.

Both in the Dual Diagnosis Capable and Dual Diagnosis Enhanced, higher portions of patients were sent by TAU to inpatient treatment services, and although not significantly different, there are less inpatient placements among the Addiction Only Services group. This can be attributed to the more intense services needed by patients with co-occurring disorders, and thus support ASAM Criteria ability to place individuals with more severe needs to more intense services. There are similar results among the Addiction Only Services and Dual Diagnosis Enhanced group on the ASI CS severity scores: both significantly reduced severity scores on a majority of the dimensions and had an increase on the ASI Employment score. The improvements in both groups suggest that the services provided in this region have the capability to deal with more acute and severe co-occurring disorders, and given the right

intensity of services both groups have successful treatment outcomes. This is in line with prior research that shows better outcomes with the right intensity and integration of services to treat both disorders (Brunette et al., 2004; Magura et al., 2003; Sharon et al., 2003). The higher mean severity at baseline seen in the Dual Diagnosis Capable and Dual Diagnosis Enhanced compared to Addiction Only Services group shows support for ASAM ability to discriminate between LOC. On ASI composite score Legal, Family and Psychological; Dual Diagnosis Enhanced is significantly more severe than both Dual Diagnosis Capable and Addiction Only Services. This is in line with previous research in the field with similar results (Sharon et al., 2003).